Application of Multicomponent Nursing Intervention to ...

Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4
121
Controlling Delirium and Duration of ICU Stay among
Critically Ill Older Adult Patient
Zahra Ahmed Sayed 1, Eman Mohamed Ebrahim Abd-Elraziek2, Islam Galal Sayed3 1 Critical Care Nursing, Faculty of Nursing, Aswan University, Egypt 2 Geriatric Nursing, Faculty of Nursing, Aswan University, Egypt 3 Chest Diseases and TB, Faculty of Medicine, Aswan University, Egypt.
Abstract
Background Few studies have investigated delirium in a respiratory intensive care unit
(RICU) population, thus knowledge is limited regarding it. Aim, the present study aimed to
investigate the effectiveness of application of multicomponent nursing intervention to
controlling delirium among critically ill older adult patients. Quasi-experimental research
design was carried out to meet the aim of this study. A purposive sample included 60 old age
critically ill patients taken from respiratory intensive care in Aswan University Hospital. Tool
1, Patient assessment sheet was used for collecting data, which included two parts: bio-
demographic data and medical data, Tool2, intensive care delirium screening checklist to
detection and monitoring delirium include eight screening area Each feature that manifests are
given one point and zero point if not manifests Ascore ≥ 4 indicated delirium.Tool3, Richmond
Agitation Sedation Scale (RASS) to predicted type of delirium. Tool4 Multiple nursing
intervention for controlling delirium. Results: Delirium was frequent in patients in the
standard care group compared with our intervention group (p = 0.04), however no substantial
differences between both groups regarding types, duration or delirium severity (P≥ 0.05),
respectively. Moreover, the duration of ICU stay was lowered in our intervention group (P=
0.001). Age was a substantial risk element for delirium development by multiple regression
analysis. Conclusion: the delirium episodes during RICU stay were established to all critically
older adults with respiratory illnesses, as anticipated, after application of a multicomponent
nursing intervention, the incidence of these adverse consequences was reduced.
Recommendation: replication of these study on the large sample size in other ICU that
provide care for critically ill older adult patients to decrease incidence of delirium within
critical care setting.
Key words: Delirium, Nursing intervention, Critically elderly ill patient, and Respiratory
intensive care unit.
accompanied by poor outcomes especially
a critical care setting, including increase
lengths of stays, increased mortality,
higher costs, overuse sedation therapy, and
physical restraints, increased accidental
beginning cognitive impairment (Pavone
care environments, delirium is especially
raved in an intensive care unit (ICU)
ranging from45% to 84% and can lead to a
number of negative outcome including the
longest intensive care unit stay, accidental
122
increase due to delirium (Mitchell et
al.,2017).
cognitive alteration (which progresses
instability of awareness and disorders in
attention, memory, thought, perception
frequency, occurrence, and consequence
(ICU), presented that a significantly higher
percentage of older adult clients developed
delirium rather than younger patients
(Jayaswal et al.,2019).
affects acutely ill older adult patients
within the critical care setting. The
American Association of Critical-Care
alteration in awareness, inattention and
either an alteration in perceptional or
thought disturbances (Cahill et al.,2017).
It is also recognized by changes in
sleep and wake cycles and exacerbates
symptoms at night, interspersed with
periods of clarity It can be dropped in the
form of hyperactivity (agitation),
mixed, yet the most common type of
delirium is hypoactive type (Bento et
al.,2018).
an increased risk of delirium, especially
during ICU stay. This often results from
infection, dehydration, microvascular
ICU, older adult patients with critical
illnesses who become delirious within six
months are more likely to die than those
who do not, with each additional day of
delirium (Ghaeli et al.,2018).It is
important to treat the underlying cause of
delirium, manage the confusion, and
minimize the occurrence of further
complications by providing safety and
ensuring the patient remains hydrated,
nourished, and as active and mobile as
possible (Schaef et al.,2019).
development in ICU, nurse and health
team additionally, family members as a
caregivers could arguably play an
important role in controlling and reducing
the development of the syndrome (Ghaeli
et al., 2018).
number of risk factors Therefore, multiple
application of nursing strategies to
decrease the number of risk factors for
delirium to prevent delirium in older
patients within ICU significant and
potentially effective intervention for
delirium, Therapeutic approaches of
cognitive impairment included appropriate
lighting, reorientation, early mobilization,
Sleeping pattern promotion, sensory
nursing care will be more effective and
useful to patients and families (Kluger et
al.,2018).
due to the client's age above 65 years was
reported for higher than 48 % of days of
hospital care services (Marcantonio et
al.,2017).
delirium include the length of hospital stay
for more than 2.3 million older people,
involves more than 17.5 million inpatient
days, and accounts for more than $4 billion
dollars of Medicare expenditures (Pastula
et al.,2017).
123
increase to other adverse outcomes in a
critically older adult patient, such as
cognitive and functional deterioration with
loss of independence, falls, extended ICU
stay, increased risk of death and
rehospitalization, Because of their long-
term interaction with patients and
providing specialized care to them, nurses
and health care provider can play a
dynamic role in the control, early
recognition, prevention, and evidence
(Gorski et al.,2017).
multicomponent nursing intervention to
disease.
application of multicomponent nursing
Research hypothesis:
intervention controlling or decreased
patients admitted to ICU.
nursing intervention is more effective on
the decrease length of stay among older
adult intensive care patients.
this study.
Respiratory intensive care unit in Aswan
University Hospital from the beginning of
October 2017 until the end of March 2018.
Sampling:
older adult critically patients taken from
intensive care unit for six months.
The total sample was selected and
distributed randomly and equally into two
groups by using simple random number
table (the first patient was selected for
implementing multicomponent nursing
which taken only the routine care of
intensive care and so on).
Control group: consisted of 30
elderly patient was selected to perform the
usual care.
elderly patient was selected for applying
multicomponent nursing intervention.
both sexes.
who are oriented
admission to ICU
participate in this study.
addicted to drugs;
124
such as psychosis, depression
participate
the data of this study. They are developed
by the researchers after extensive and
relevant review of literature. The validity
& reliability of these tools were revised by
a panel of medical of respiratory disease
staff, critical care nursing and geriatric
nursing experts, and then pilot study was
done.
the data of this study (developed by the
researchers), which included two parts as
follows:
older critically ill patients as gender, age,
weigh, height, hospitalization reason.
collect medical data, past history,
laboratory investigation, APACHE II
duration of ICU stay and risk factors that
are contribute to delirium in older adult
critically patients who are admitted to
respiratory intensive care unit.
Second Tool: Intensive Care
Delirium Screening Checklist (ICDSC):
Bergeron, et al., 2001)
To detection and monitoring
The Scoring system tool II:
The checklist screening scale
ICU and then performed every 12 hours to
identify patients with delirium, the
screening checklist include eight screening
area: level of consciousness, inattention,
inappropriate speech or mood,
disorientation psychomotor agitation or
manifests are given one point, with zero
points if not manifests within the specified
time frame, a score ≥ 4 indicated delirium.
Third Tool: Richmond Agitation
al.,2018).
the sedation or agitation level. Performed
by researchers.
The RASS can describe their level
of alertness or agitation. Patient alert and
quiet (score 0), patient behavior that's
restlessness (score +1) agitation (score
+2), the patient is extremely agitated as
pulls or removes tubes and catheter (score
+3), a combative patient can violent and
danger to staff (score + 4). The Patient has
eye-opening and eye contact, which is
sustained for quite 10 seconds (score -1).
The client has eye-opening, but this is
often not sustained for 10 seconds (score -
2), Patient has any movement in reaction
to the speech, exclusive of eye contact
(score -3), If a patient doesn't answer to
speech but can physically be stimulated by
shaking shoulder at that time rubbing
sternum (score -4), the client has no
response to speech or physical stimulation
(score -5).
125
researchers at different times every shift to
control and prevent the development of
delirium in ICU. It consisted of the
following:
sleep.
Second nursing intervention,
member during visiting time within ICU
reorient older adult including time, date,
location within the hospital ,daily
information about his or her plan of care
including, Names of doctors, nurse and
nursing assistant for the shift, Making sure
a clock with the correct times is visible,
Third nursing intervention,
Sensory stimulation include:
Enhancing hearing and vision by
creating a quiet, private environment
reduce background noise by pulling the
curtain in the room and closing the door.
If a person wears hearing and
vision aid(s), make sure they are being
used, and are clean and operating.
Adjust if needed, and bringing in
objects from homes such as religious
objects, family photos, favorite clothing,
or blanket.
every word, precisely and accurately in a
fully formed manner, reinforce your
speech with gestures, pointing, and touch.
Fifth nursing intervention
while they are in the ICU. For patients that
are able, assistance during walking. For
those who are incapable to walk, passive
and active range of motion must be
performed. Walking at least 2-3 times per
day is essential for physical and mental
wellbeing,
patient’s usual sleep/rest patterns,
uninterrupted sleep at night, Provide
mouth care, Offer back, hand, or foot
massage, a warm blanket, Provide low
lighting and Minimize noise within ICU.
Outcome measures
of delirium among the whole study
population: Severity of delirium was
measured using the Delirium Index (DI),
(McCusker etal.,2004) which included
(disorders of attention, thought,
each scored on a scale from 0 (absent) to 3
(present and severe). The total DI score
126
indicating greater severity.
both groups.
Ethical considerations
and the head of the intensive care unit).
- Written approvals were taken
presenting ourselves to them and
explaining the purpose of the study.
This study was carried out through
three consecutive phases:
literature in various aspects of the delirium
problem among older critically ill patients.
Content validity
5 experts in medical respiratory disease,
critical care nursing, and geriatric nursing
field and it equaled 91% .
Reliability: The reliability of the
tool was calculated statistically by alpha
cronbach test (r=0.82).
during a period of six months from the
beginning of October 2017 until the end of
March 2018. This was done during the
routine work of the hospital at every shift.
The assessment sheet requires about 15-20
minutes filling; about 1-2 critically elderly
patients were collected per week.
- At the intensive care unit, the
researchers introduced themselves and
study.
(control group) for usual care and 30
patients (study group) for multiple nursing
intervention.
components, preventive measures,
implementing multicomponent nursing
patient in the ICU and the informal
caregiver to the delirious older adult
patient. The time needed for completing
the questionnaire was ranged from 30 to 45
minutes for each patient.
- After obtaining the patients
study.
record.
- Multiple nursing intervention
enrolled in the study.
127
to facilitate achieve goals.
- The researchers explain and
implement multiple nursing interventions
patient's condition. Each session ranged
25to 35 minutes and including 5 minutes
for discussion and feedback. each session
content was as follow:
First session: this session
initiated by the researchers introduced
themselves to the patients telling them; the
purpose of the meeting, orient patients
regarding nursing management. Contents
about delirium and methods to prevent in
ICU. This session finished with a summary
of its content and feedback from the
patient.
applied by researchers it includes (improve
oxygenation, daily reorientation, and
cooperative and interested in a given topic
and asked to continue the nursing
management.
implemented during the night shift the
remain three items from nursing
intervention was applied by researchers it
includes (improve communication,
communication skills during all session to
improve patients communication,
researchers was demonstrated exercises. A
complete explanation of these exercises,
the greatest patients were cooperative and
interested in a given topic and asked to
continue the nursing management.
evaluation rate of delirium in ICU for all
studied patients through tool II, and
evaluation length of stay in ICU at
discharge or transferred to ward.
Statistical analysis:
presented as mean and standard
deviation. Chi-square and Fisher Exact
tests were used to compare qualitative
variables. Mann-Whitney test was used to
compare quantitative variables in case of
non-parametric data. P-value was
0.05.
Results:
subjects (study group 30 subjects &
control group 30 Subjects), 70% of the
control group were males in while 63.3%
of our study group were males, no
substantial variance between both groups
regarding age, marital status and the level
of education as shown in table (1).
Table (2): Regarding the clinical
characteristics of all the study population,
A major significant variation between both
groups as regard the length of ICU stay (P
≤ 0.01) while , no significant difference as
regard the other parameters as shown in
table (2).
a highly substantially variation between
both the study and control groups
128
incidence of delirium in our study group
was lowered than the control group with a
substantial variation (P = 0.04).
substantially significant variance between
incidence of delirium from second day
morning to the sixth day morning (P
≤0.01) as shown in table (5).
Table (6): Regarding the
distribution of delirium characteristics
Table (7): The multivariate
predisposing risk factors for the
development of delirium was shown in
table ( ), demonstrated that for each 1-
point increase in age of our patients, there
were 1.7 times (odds ratio [OR], 95%
confidence interval [CI], 0.13-5.8)
controlling for other risk factors of
delirium including malnutrition,
dehydration, immobility, electrolytes
risk factors leading to delirium between
both groups. Infection & dehydration
the study group. Meanwhile, in the control
group malnutrition, electrolytes
factors of delirium. Furthermore, in both
groups, orthopedic surgery, functional
important risk factors of delirium.
Discussion
adults which can have deleterious
consequences. Is accompanied by,
and length of hospital stay as well as
increased use of healthcare services and
costs (Gual et al.,2018).
syndrome in the ICU, particularly in those
who have hospitalized ICU and/or
severely compromised medico-surgical
application of multiple nursing
interventions in controlling delirium
with respiratory problems. This study
concluded that delirium episodes during
hospitalization in RICU were established
to be common in all older adults with
respiratory illnesses, as anticipated, but
with the use of multicomponent nursing
intervention, the incidence of these
adverse consequences reduced. In
nursing program had no effect on the
severity or duration of the delirium
incident.
component nursing intervention comprises
carry out by health care providers. Most
studies have delivered recommendation
that a multi-component nursing
effective when centered on synergistic
collaboration between the several
2019) In the study by Cheraghi et al.,
129
multifactorial intervention based on
patients with open heart surgery the rate of
delirium has been significantly decreased.
In this regard, the study of Martinez, et
al., 2012. Showed that the effectiveness of
the non-pharmacological interventions
more than traditional care.
occurred, the current study showed that the
intervention did not shorten its duration.
This result correlates with a study done by
Deschodt et al.,2012, who shown that
their inpatient geriatric consultation
patients with hip fracture, along with no
effect on the duration or severity of
delirium. Taken together, these results
indicate that the most significant strategy
to report delirium is its prevention. In
accordance with their findings, findings,
the current study showed that, the
incidence of delirium was lower in our
intervention group.
2012, showed that multifactorial
teaching about the environmental
interventions can decrease the incidence of
delirium in open-heart surgery
meta-analysis explore that non-
found to be effective in declining the rate
of both falls and delirium in critically
elderly patients during hospitalization
Hshieh, et al., 2015.
out that no effect on the prevalence of
delirium. This was due to long time
intervals of assessment of the patients
about delirium every 2 days was not
probable. Similarly, Kalani et al., 2013,
indicated that the rate of delirium was only
one occasion in their traditional care
group, their nursing intervention (Seeing
family members out of the visiting hours
and listening to the radio for at most one
week) had no significance on the incidence
of delirium with no statistically substantial
variance between their two groups.
The main conclusion of
was that their MID-Nurse Study, a
scheduled non-pharmacologic nurse-led
that the intervention may decline delirium
incidence, prevalence, and severity. While
their results are positive, confirmation
from the complete MID-Nurse reseaches is
required before applaying that the
intervention is effective. From the
researchers' point of view, the delirium
rate was decreased may be due to the
implementation of multicomponent
period of time stay in ICU until
discharged.
duration of ICU stay among studied
critically elderly patients in the
intervention study group; it was observed
that, the length of ICU stay has been
significantly reduced than the control
group. This was coordinated with the study
by Needham and colleagues., 2010,
reported a shorter duration of ICU stay and
also, shorter length of hospital stays
following the application of their quality
enhancement program. However, the
different between both groups, This
finding was opposed to another study by
Kang et al., 2018, a recent systematic
review reported that non-pharmacological
130
the duration of delirium and the delirium
occurrence, but not the ICU length of stay
and ICU mortality.
view, multicomponent nursing
delirium rates because of regular detection
and elimination of the risk factors and that
are simple to carry out by health care
providers.
of delirium established that for each 1-
point increase in age of our patients, there
were 1.7 times (odds ratio [OR], 95%
confidence interval [CI], 0.13-5.8)
of delirium including malnutrition,
associated with delirium were APACHE II
after controlling for dementia, mechanical
ventilation, age, the non-pharmaceutical
practice, and home-based antipsychotic
to be the foundation of improving an
assessment system to help educate nursing
staff on delirium and provide high-quality
nursing services that go beyond the level
of symptom control.
main limitation included patients who
were mechanically ventilated who were
excluded from the study because a higher
acuity level, and administered large dose
of sedation for prolonged periods of time,
which could introduce bias in response to
intervention and results analysis another
limitation, the small number of
participants was lower than the desired
sample size in the classic care group due to
a high rate of drop-out.
131
Table (1): Frequency distribution of Socidemographic data for critically older
adult patient with delirium for both group n =60 (n= 60)
Socio-demographic data Study group (n=30)
Control group
15
7
3
5
0
50
23.3
16.7
10
0
15
9
1
5
0
50
30
3.3
16.7
0
0.741
Data are presented as mean ± SD, or number and percentage (%).P-value<0.05 is considered
statistically significant
Table (2): Frequency distribution of Clinical characteristics of all the study
population (n=60)
P value
No % No %
Malnutrition
10
7
13
8
3
2
33.3
23.3
43.3
26.7
10
6.7
13
11
13
8
1
4
43.3
36.7
43.3
26.7
3.3
13.3
0.875
132
Current
medications
Benzodiazepines
Antihistamines
Narcotics
(Morphine)
Sedatives
(Ambien,
Lithium
APACHE II
score (Mean
Length of stay in
2.63 ± 1.38 5.87 ± 1.995 0.001
statistically significant. COPD: Chronic obstructive airway disease. SOFA: Sequential Organ Failure
Assessment. APACHE: acute physiology and chronic health evaluation.
Table (3): Comparison of Richmond Agitation Sedation Scale (RASS) between
both groups
P value
No % No %
Positive 3 10 22 73.33
statistically significant.
Table (4): Comparison of the incidence of delirium rates by (Intensive Care Delirium
Screening Checklist) between both groups
Incidence of delirium
Total score 0-8 3.73±1.96 5.43±1.194 0.001**
Data are presented as mean ± SD, or number and percentage (%).P-value <0.05 is considered
133
Table (5): The frequency of the cumulative incidence of delirium from the second
day to the seventh day after nursing intervention between both groups
Study groups Control group P value
Present
The Second morning 9(30.0) 21(70.0) 13(53.3) 14(42.4) 0.03*
The Second evening 9(30.0) 21(70.0) 16(53.3) 14(42.4) 0.03*
The third Morning 7(23.3) 23(76.7) 14(42.4) 13(53.3) 0.05*
The third evening 7(23.3) 23(76.7) 16(43.3) 17(56.7) 0.04*
The fourth morning 8(26.7%) 22(73.3) 12(40.0) 18(60.0) 0.04*
The fourth evening 7(23.3) 23(76.7) 13(43.3) 17(56.7) 0.04*
The fifth morning 6(20.0) 24(80.0) 13(43.3) 17(56.7) 0.04*
The fifth evening 5(16.7) 25(83.3%) 13(43.3) 17(56.7) 0.02*
The sixth morning 4(13.3) 26(86.7%) 8(26.7%) 22(73.3) 0.08
The sixth evening 3(10.0) 27(90.0%) 5(16.7) 25(83.3%) 0.19
The seventh morning 1(3.3) 29(96.7) 3(10.0) 27(90.0%) 0.23
The seventh evening 0(0.0) 30(100.0) 3(10.0) 27(90.0%) 0.23
Data are presented as number and percentage (%).P-value <0.05 is considered statistically
significant.
Table (6): The distribution of delirium characteristics in the study and control
groups
(%) N (%) N
(range 0–21)
134
Table (7): Multivariate logistic regression analysis of the factors that was shown
to be predictors of delirium
Delirium P-value OR 95.0% C.I.
Lower Upper
Risk factors of delirium
Electrolyte imbalance 0.596 0.559 0.221 13.809
Dehydration 0.560 0-.570 0.083 3.852
Sensory impairments 0.320 1.114 0.338 27.416
Functional impairments 0.626 - 0.437 0.112 3.736
Hypoxia 0.706 -0.679 0.015 17.170
Fig.1: Distribution of the risk factor for delirium in older adult patient with
delirium in critical for both group (n= 60)
Conclusion
rate and duration delirium and improve the
patient outcome among the critically ill
elderly patients.
Financial support
No
135
Acknowledgements
Aswan university hospital, all nurses and
physicians at the unit.
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care.
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